Rev Saúde Pública 2005;39(5)
www.fsp.usp.br/rsp
Professional competence and contraceptive
care
Escolástica Rejane Ferreira M ouraa and Raimunda M agalhães da Silvab
aDepartamento de Enfermagem. Faculdade de Farmácia, Odontologia e Enfermagem. Universidade Federal do Ceará. Fortaleza, CE, Brasil. bCentro de Ciências da Saúde. Universidade de Fortaleza. Fortaleza, CE, Brasil
Correspondence:
Escolástica Rejane Ferreira Moura
Av. Filomeno Gomes, 80 Apto 401 Jacarecanga 60010-280 Fortaleza, CE, Brasil
E-mail: [email protected]
Financed by the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico (FUNCAP) and Departamento de Pós-graduação em Enfermagem of the Universidade Federal do Ceará (UFC). This study was conducted in the 4a Regional de Saúde do Ceará [4th Regional Health District of Ceara]. Based on a Doctoral thesis presented at the Universidade Federal do Ceará, in 2003.
Presented at the 15th Congresso Internacional em Questões de Saúde da Mulher [International Conference on Issues in Women’s Health], São Pedro, SP, in November, 2004.
Submitted on 6/20/2004. Reviewed on 3/18/2005. Approved on 6/5/2005. Keywords
Familiar planning services. Contraception. Professional
competence. In-service training. Health education. Evaluation. Family health.
Abstract
Objective
To evaluate the technical competence of professionals carrying out activities related to contraceptive care.
Methods
Evaluative research in the field of health was conducted in eight districts of the State of Ceara from July to September 2003. Data was collected by means of interviews with 29 nurses working in the Family Health Care Program within these districts and 50 people being attended by this program. Observations of the Family Health Care Units were a complementary source of data within this study.
Results
The majority of nurses had received some form of training regarding contraception and the technical norms regulating their use. However, professional barriers were reported by the nurses and others were identified by lay persons being attended by the program, that indicate the need to provide better training for professionals engaged in this area of care. The nurses recognized they had deficits in information and communication skills as well as technical deficits in dealing with contraception.
Conclusions
There are gaps in professional competence with regard to contraceptive care that, when associated to the lack of systematization of team work, generates distortions in the quality of care. Team work was characterized by the lack of definition of team members’ specific attributions and tasks.
INTRODUCTION
Professional competence in the field of contracep-tion should include up-to-date technical, scientific and cultural knowledge, directed towards attending to the sexual health and reproductive needs of clients. This includes skill in counseling, informing and communi-cating adequately, participating in the decision-mak-ing process with respect to contraceptive methods (CM) and lending support to the client respectfully. With this respect, the Brazilian Ministry of Health7 also suggests that professionals should be prepared to deal with the myths, preconceived notions and
errone-ous perceptions that individuals accumulate with re-spect to CM, sexuality, reproductive health, follow-up of their children, among other things.
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tained and what shouldn’t be, constituting itself in an instrument in the decision-making process.
This study was conducted in eight districts of North-eastern Brazil (Aratuba, Aracoiaba, Baturité, Capistrano, Guaramiranga, Itapiúna, Mulungu and Pacoti), from July to September 2003, and included both urban and rural zones. At the time, 30,116 families were registered in the Family Health Program (FHP), corresponding to 87.8% of the population in this area.10
Subjects were selected according to the following criteria of inclusion: a) nurses: were involved in con-traceptive care as members of the FHP team and b) lay persons: women or men participating in or who wished to participate in the FHP. Twenty-nine (90.6%) nurses from the region and 50 of the people attend-ing the FHP were interviewed. Saturation of the re-plies was the criteria adopted for delimiting the number of interviews conducted with people attend-ing the service, that is, data was collected without previously determining the number of interviews and as new events became depleted, the sample was con-sidered satisfactory. 12
Interviews were conducted according to two itiner-aries, one directed towards the nurses and the other towards the lay persons, containing both open and closed questions that were pretested in two Family Health Care Units (FHU).
The results were organized with reference to the Technique of Category Analysis of the Method of Content Analysis.1 Events were codified and enumer-ated so as to facilitate the process of quantification. The itineraries of the interviews with lay persons were enumerated from one to 50 and those of the nurses were enumerated from one to 29. Information pro-vided by nurses was codified with the letter “E”, while data provided by lay persons was codified with the letter “U” for users. Fragmented reading of all the material was conducted, with the intent of dividing it into units of convergent and divergent meaning, re-sulting in four analytical categories: access to and quality of training in contraceptive care; access to updated manuals and technical norms concerning contraceptive care; Professional competence in con-traception in the nurses’ discourse and according to the experiences of those attending the services.
Research subjects were guaranteed anonymity, pri-vacy, that their image would be safeguarded, non-stigmatization, and that information would not be used in a manner that could be detrimental to people or to the communities, so as to respect the ethical aspects of research.
ple’s freedom of choice. CM currently available and authorized in Brazil include behavioral methods, masculine and feminine condoms, diaphragms, sper-micides, IUDs, oral and injectable hormones, tubal ligation and vasectomy.8
Certain elements were established with respect to contraceptive health care in family planning so as to assure that good quality assistance be offered to the population. These elements include offering choice of methods; information given to clients; in-terpersonal relations; professional competence, fol-low-up and continuity mechanisms; and the avail-ability of the appropriate network of services.2 How-ever, professional competence is one of the most difficult aspects to evaluate, for clients tend to evalu-ate this aspect of care according to the time spent with them and the support they receive more than to their technical knowledge and professional skills. According to the same author, clinical incompetence is rarely reported for the documentation concerning clinical procedures and their consequences was poor and scarce. An exception was a detailed study on death due to sterilizations in Bangladesh, resulting from non-sanitary physical circumstances, precari-ous conditions of asepsis, gross technical errors or the application of inappropriate medical standards. One of the reasons for the scarcity of studies may be political in character, for serious technical problems may not be published, in light of the breach in col-laboration of that professional in the improvement of his/her performance. The status bestowed upon physicians in particular may be another reason, since clinicians have been protected by the majority of public reports.2
Considering the above mentioned issues, the fol-lowing questions arise: Are Family Healthcare teams sufficiently trained to offer contraceptive care? Do they have access to manuals and technical norms that may guide assistance? What are the difficulties or obstacles that arise in dealing with contracep-tion? How do people seeking care perceive the per-formance of health teams with respect to contracep-tive care?
Therefore, the objective of this study was to evalu-ate the technical competence of professionals en-gaged in contraceptive care.
M ETH O D S
main-!
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Professional competence and contraception Moura ERF & Silva RM
RESU LTS AN D D ISCU SSIO N
Access to and quality of training in contraceptive care
Twenty-one (72.4%) of the nurses interviewed had participated in some form of training in contracep-tive care. The rest of the nurses, 8 (27.6%) that had no such training recognized the fact as a deficiency and expressed interest in acquiring this training.
Despite the fact that the majority of nurses had al-ready had access to courses concerning this theme, almost all of them affirmed they had some sort of defi-cit in performing activities related to contraceptive care. Training is one of the ways of improving techni-cal competence, however it is not a synonym for qual-ity. The kind of training proposed2 is based on compe-tencies being monitored in service periodically. In this kind of training, the instructor evaluates the level of comprehension and assimilation of the participant’s training in practice, rather than evaluating the time spent in training or the student’s assimilation of infor-mation. Expanding this discussion, the fact that pro-fessionals are not apt is due, in part, to professional training that does not propitiate the development of competencies that can prepare them to enhance their problem-solving capacities in order to confront every-day life situations in a creative way, giving due appre-ciation to learning to learn and to team work.9 The same author emphasizes that training should be con-tinuous, institutionalized, multi-professional, centered on the work process and directed towards improving the quality of services, including the effective partici-pation of the population attending these services.
Indeed, the methodology that has been employed in family planning/ contraceptive care training (1993 to 1995) is quite positivist, characterized by the pre-dominance of the theoretical component and employ-ing a process of evaluation centered on the knowl-edge assimilated by the participant during the classes. Certainly this kind of training did not generate sig-nificant improvements with respect to technical per-formance, for neither the field of action of these pro-fessionals, nor their working conditions or the con-tinuous process of training in service was taken into consideration. However, Ceara now disposes of
“Instrumentos de Melhoria da Qualidade em Atenção
Primária à Saúde” [Instruments for the Improvement
of the Quality of Primary Health Care”] that compre-hends the area of family planning/contraception. These instruments were created by means of a collec-tive process involving the participation of experts, professionals attending laypersons seeking family planning and contraceptive care, laypersons
attend-ing these services, and consultants from three inter-national cooperation agencies Program for Interna-tional Education in Reproductive Health (JHPIEGO), Management Sciences for Health (MSH) and Center for Communication on Programs(CCP). These are self-applicable instruments that are easy to use and that facilitate self-evaluation as well as the learning process within health teams, being a continuing edu-cation tool.11 However, it is necessary to make these instruments available to the universe of health pro-fessionals that deal with this area of care, as a strategy to improve their technical performance.
Access to manuals and up-to-date technical norms for contraceptive care
Eighteen nurses (62.1%) stated they had access to this kind of material and presented the Ceara State Department of Health (14), the Ministry of Health (8), the Sociedade Civil do Bem-Estar Familiar
(BEMFAM) [Family Welfare Civil Society] (5), the
Panamerican Health Organization (PAHO)(3) and texts provided in the Specialization in Family Health Care Course as their main sources (2). However, several of these nurses claimed that they had no time for read-ing and for studyread-ing these manuals due to the activi-ties involved in their daily routine. The other 11 (37.9%) nurses stated they did not have access to manuals and/or to technical norms.
Despite the considerable contingent of nurses that had access to instructional resources, this access should be universal. Managers must value and stimu-late continuing education in services, mobilizing employees to form local study groups that function on a regular basis.
The norms regulating women’s health activities constitute one of the programmatic areas of the Min-istry of Health that distinguishes itself as a tool for the development of human resources, of health edu-cation and as a logistic support. It is an activity that is based on the supported of a broad spectrum of class organs, universities, and councils amongst others. When the Programa de Assistência Integral à Saúde
da Mulher (PAISM) [Integral Health Assistance
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members of the health team, thus contributing to-wards the fact that certain conducts adopted by the services are out-to-date. These authors also state that the majority of schools of medicine and of nursing do not include family planning in their undergradu-ate programs and those that do include them, only discuss contraceptive methods, putting aside aspects such as reproductive and sexual rights and commu-nication techniques, among others.
Throughout the period of fieldwork, the municipal departments of health received manuals of technical norms from the Ministry of Health directed towards professionals and managers that deal with
contracep-tion. The quantity of manuals proved to be insuffi-cient, restricting the individual access of profession-als to the material. Another aspect identified was the gap left by the Ministry of Health between the last version of the family planning manual7 and the cur-rent revision,8 that is, that is, from six to seven years, when new information should already have been in-corporated into professional practice.
Professional competence in contraceptive care from the perspective of nurses and of people attended by the services.
Five nurses (17.2%) stated that they felt prepared
Table - O bstacles to Professional competence in contraceptive care and scientific evidence. Regional H ealth D istrict of Ceará (Northeastern Brazil), July to September, 2003.
Professional obstacles
My uterus was irritated. The doctor said it was because of the pills [COC] and that I should stop taking them. (U14).
W hen w e reach the age of 35 they [ doctors, nurses and nurse assistants] don’t want to give us pills anymore [COC] (U17, U6).
I become insecure when it comes to determining at what age a w oman shoul d stop usi sng the combi ned oral contraceptive...(E13).
It was not carelessness that led me to become pregnant of my second child. It was because the doctor told me I could not take the pi l l because I w as breastfeedi ng. I w as al ready menstruating. (U42).
W hen a w oman w ho has concl uded her thi rd month of postpartum, i s breastfeedi ng excl usi vel y and i s not menstruating, says she wants to take the pill,... I only offer it to her after she has undergone a pregnancy test (E24). I have doubts about w hen to i ni ti ate the combi ned oral contraceptive among patients who are breastfeeding: if the child is eating other foods is the mini pill still effective? After six months must the woman stop taking the mini pill? (E12)
The nurse didn’t give me my pills because I had just begun to menstruate two days before my consultation. She said it was for my ow n good, that if I began to take the pill I w ould become pregnant. (U19).
I wanted a tubal ligation, but the doctor Said I was too young (she was 24 years old) and that I had too few children (she had two children).
You see 14 or 15 year old girls already taking hormones, that’s not right (E2). Pills or injections are not the best methods for adolescents (E28).
I recommend the suspension of the pill (COC) for six months w hen it has been used continuously for tw o years. I have attended women who have been using it continuously for up to five years, then I tell them to stop taking it for God’s sake! (E22).
Before being referred for IU D insertion, w e must undergo prevention (PAP’S Smear) because if we don’t the doctor will not insert the IUD (E23).
Scientific evidence
The Ministry of Health (MH) recommends the use of COC in
cases of irritated uterus or cervical ectopia.8
The M H recommends the use of CO C until the age of 40 w i thout restri cti ons; from that age on the i ndi cati on i s maintained, however with restrictions, since the risk of cardi-ovascular disease increases with age and may be greater for those taking the pill. However, if the person being attended is 35 or older and smokes more than 20 cigarettes daily, COC is
counter indicated. 8
The pi l l and i nj ectabl e contracepti ves that are based excl usi vel y on progestagen may be uti l i zed among breastfeeding women six weeks after childbirth; the use of CO C and combi ned i nj ectabl e contracepti ves may be initiated six months after childbirth, for they may reduce the
quantity of milk and effect child development.8 In the case of
the client who had already begun to menstruate, it is probable that her chi l d w as no l onger breastfeedi ng excl usi vel y. Therefore, the combined hormones would also not be counter indicated. There is no need to ask for a pregnancy test if the patient is breastfeeding exclusively, for the chances of her being pregnant are practically null.
The pill may be taken initially any day of the menstrual cycle, if the professional prescribing it is reasonably sure that the cl i ent i s not pregnant. In order to prescri be the pi l l , the professional needs to consider the following information: the menstrual cycle began less than seven days ago; the woman gave birth less than four weeks ago; the abortion took place less seven days ago; or the woman gave birth six months ago, is breastfeeding frequently and is not menstruating; or she did not have vagi nal sexual i ntercourse si nce her l ast menstruati on; or she used another CM correctl y i n her
previous sexual activities.6
According to the Law no. 9.263/96, that is concerned with family planning, volunteer sterilization is permitted for men or women with full civil capacity and who are over 24 years
of age or, have at least two live offsprings. 8
The theoreti cal concern w i th the use of the pi l l i n the beginning of adolescence has no scientific basis. Its use is recommended, without restrictions, from menarche onwards. Contracepti ves based sol el y on progestagen, are recommended with restrictions from menarche to the age of
16 due to concern with respect to the hipoestrogenic effect.8
The Ministry of Health advises that there is no need to interrupt the use of the contraceptive method, for there is no scientific evidence that justifies this practice and it is a cause of undesired
pregnancy.8
There is no scientific evidence that justifies oncologic cytology
as a pre-requisite for the insertion of the IUD. 3
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to deal with the issues involved in contraceptive care; 17 (58.6%) recognized they had technical difficul-ties in evaluating contraindications; 10 (34.5%) had difficulties in managing collateral effects and/or com-plications. Eight (27.6%) reported difficulties in in-forming lay persons about the correct way of using some of the CM, being that, for two of these, this was considered a technical issue and for the remaining nurses the difficulties were related to the lack of time associated to the large demand. Guaranteeing free choice with respect to contraceptive method was con-sidered a challenge by 14 (48.3%) nurses, not be-cause of the technical issues involved, but bebe-cause of the small variety of CM available at the service.
The nurses that recognized they had difficulties in evaluating contra indications were referring exclu-sively to the hormonal contraceptives (pills and in-jections) and basically to the breastfeeding period. As to the management of collateral effects, the doubts expressed also referred to hormonal methods, includ-ing, predominantly, changes in the menstrual cycle.
Nurses’ and laypersons’ statements were consoli-dated in the Table, being classified as obstacles to pro-fessional competence in contraceptive care, and char-acterized as inappropriate conducts adopted by physi-cians and/or nurses and nurse assistants in the man-agement of CM. Scientific evidence regarding these conducts are presented in conjunction with them.
This data confirms the need to implement continuing education among professionals working in this field. Technical lapses in professional activity lead, for exam-ple, to the professional’s denial of patient’s control over fertility due to extraneous criteria.2 Another aspect of this issue is that clients are overburdened with the con-sequences of the use of inappropriate techniques, such as, for example, unnecessary pain, infections and other serious collateral effects; and, under certain circum-stances, even death. The discourse of a woman who was attending the service and who had already experimented the IUD, confirms the above observations: “I was al-ways feeling the inflammation and, each six months I came back for a revision of the IUD and I always had
something or other”(U14). And, according to another
woman who attempted to have an IUD inserted, but was not successful: “I underwent preventive treatment to try to have an IUD inserted, but it wasn’t possible. My
uterus was perforated” (U29).
As to the nurses that reported difficulties in inform-ing clients with respect to the correct usage of contra-ceptive methods, one was referring specifically to the diaphragm and the other one was referring to injectable hormones. The fact that these methods were not easily
available in the services and, therefore, had scarcely been managed was utilized by professionals as a justifica-tion for their lack of competence with respect to their correct usage. The statements below confirm this:
“I don’t feel secure about informing (clients) about IUDs and diaphragms; after all, these are methods that we scarcely mention, for they’re never available
here.” (E6)
“I find it difficult to teach (them) about the trimester injection, because it was available for a while, but it has now disappeared. We usually talk more about the
methods that are available here.” (E20 and E21)
These statements indicate the habit of informing cli-ents only about CM that are available at the services. However, clients have the right to be informed about all existing methods, even those not available at the health care unit, for she/he may try to acquire them through other sources and there should be information regarding these sources available at the health care services in which he/she were first attended.
This study also indicates that the small variety of CM available and/or the irregularity of their supply at the health centers represents an obstacle to the management of counter indications and to the cli-ent’s freedom of choice regarding contraceptive care, since the latter tend to take the risks related to those methods that are available. Thus the advice or deci-sions taken by professionals tend to be underesti-mated, threatening the effectiveness of technical cri-teria and conducts. The stories narrated by nurses explicit this finding:
“Hypertensive women whose partners refuse to use condoms, I don’t have any other method to offer them... do I offer them pills? Some of them say that if we don’t give them pills, they will buy them. So it’s better to offer them pills, at least they will be
fol-lowed up by us”. (E28)
“A hypertensive woman, for example, if I suspend the pill, she’ll say that I’m “bad”, she’ll say that I
“don’t know anything”. (E6, E16)
“The population can’t buy (CM), so they take what’s available and this compromises our performance!”.
(E20, E21, E24, E25 and E27)
Furthermore, nurses reported situations that confirmed physician’s lack of preparation regarding contraceptive care. One of them stated: “The doctors should become
more involved.We refer a woman presenting
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back to us without having done anything for them”(E10).
And another nurse reiterated: “Frequently they(the doc-tors) are the ones who refer them (the women) to us. This happens with me, with (...) and I think it happens with
other nurses as well” (E8). Within the field of activity of
the nurse E27, this kind of omission and lack of prepara-tion on the part of physicians is so frequent that Within the field of activity of the nurse E27, this kind of omis-sion and lack of preparation on the part of the physician is so frequent that the nurse took the initiative of assum-ing the full responsibility for contraceptive care and she emphasized: “Once, I attended a woman who was over 40 years old, had sever hypertension and had a medical prescription for a combined pill. From this moment on I decided that within my sphere of action I would take on
responsibility for all the family planning” (E27). With
respect to this issue it should be stressed that family health-care is a proposal based on team work that should be carried out by the physician, the nurse, the nurse’s assist-ant and community health agents that are co-responsible for the health of 1,000 families.
Therefore, the participation of each and all team members in the family planning activities so that the nurse isn’t overburdened and her competence is not compromised is fully recognized. On the other hand, the statements of the two research subjects mentioned above brought the issue of professional competence on the part of doctors, nurses and nurse assistants (to a lesser degree) into discussion, for it seems to mark the centralization of the supply of contraceptive care
REFEREN CES
1. Bardin L. Análise de conteúdo. Lisboa: Edições 70;
1977.
2. Bruce J. Fundamental elements of the quality of
care: a simple framework. Stud Fam Plann 1990;21(2):61-91.
3. Díaz M, Díaz J. Qualidade de atenção em saúde
sexual e reprodutiva: estratégias para mudanças. In: Galvão L, Díaz J, organizadores. Saúde sexual e reprodutiva no Brasil: dilemas e desafios. São Paulo: Hucitec; 1999. cap. 8. p. 209-33.
4. Díaz M, Faúndes A, Marchi N, Arce XE, Díaz J.
Comparición del desempeno del DIU TCU 200B insertados por médicos o enfermeras. Revista Iberoamericana de Fertilidad 1992;9(5):53-8.
5. Garcia-N unez J. Avaliação em planejamento
familiar: um guia para administradores e avaliadores. Salvador: Pathfinder Internacional; 1993.
6. Hatcher RA, Rinehart W, Blackburn R, Geller JS,
Shelton JD. O planejamento familiar pode beneficiar a todos. In: Hatcher RA, Rinehart W, Blackburn R, Geller JS, Shelton JD. Pontos essenciais da tecnologia de anticoncepção. Baltimore: Escola de Saúde Pública Johns Hopkins; 2001. cap. 2. p. 2-1-2-2.
7. Ministério da Saúde. Assistência ao planejamento
familiar. Brasília (DF); 1996.
8. Ministério da Saúde. Assistência em planejamento
familiar: manual técnico. 4a ed. Brasília (DF); 2002.
9. Santana JP. A formação profissional e a educação
permanente em saúde. Bol Inf Assoc Bras Enferm 2002;44(2 ):5.
10. Secretaria da Saúde (SES-CE). Sistema de Informação da Atenção Básica (SIAB). Fortaleza: Núcleo de Informação em Saúde; 2003.
11. Secretaria da Saúde (SES-CE). M etodologia de melhoria da qualidade em atenção primária à saúde: instrumento de avaliação e supervisão. Fortaleza: SESA/NUORG; 2002. p. 120.
12. Trentini M, Paim L. Pesquisa em enfermagem: uma modalidade convergente-assistencial. Florianópolis: UFSC; 1999. p. 162.
among these three professional categories, particu-larly the doctor and the nurse. Regarding this theme, the concentration of activities and responsibilities on a single professional diminishes the technical com-petence with which some activities are undertaken.3
Follow-up consultations of women taking the pill, injectable contraceptives and IUD may be conducted by nurses or trained assistant nurses. Indeed, in some services, apparently, even IUD insertions may be car-ried out by nurses as well or even better than when they are inserted by doctors.4
In conclusion, the lack of systematic organization of team work, with tasks and attributions clearly de-fined was perceived in this study. Thus, the use of the Methodological Instrument for Quality Improvement as a tool utilized to lend support to the continuing education process in contraceptive care is suggested. Furthermore, future studies should be designed so as to discuss professional competence from the perspec-tive of team work, which proposes the division of tasks and integrated assistance.
ACKN O W LED GEM EN TS
